Nursing And Healthcare-associated Pneumonia Patients Research Articles

Positive Rate and Utility of Blood Culture among Nursing and Healthcare-associated Pneumonia Inpatients: A Cross-sectional Study.

Objective Although blood cultures to identify the presence of bacteremia are recommended for nursing- and healthcare-associated pneumonia (NHCAP), the incidence of true bacteremia and the relationship between true bacteremia and the outcome remain unclear. Physicians can therefore sometimes be confused regarding whether or not blood cultures should be obtained for NHCAP patients. This study assessed the incidence of true bacteremia and the relationship between true bacteremia and the outcome of NHCAP in a Japanese hospital setting. Methods We retrospectively analyzed NHCAP patients hospitalized between April 2016 and March 2021. The primary outcome was the incidence of true bacteremia in blood cultures. The incidence of true bacteremia was also examined according to quick Sequential Organ Failure Assessment (qSOFA) and A-DROP scores. In addition, we compared the incidence of true bacteremia between survivors and non-survivors. Results In total, 205 patients were included in this study. Blood cultures were obtained from 150 of the 205 patients (73.2%). Positive blood cultures were detected in 26 patients (17.3%), of which only 8 cases (5.3%; 95% confidence interval, 2.3-10.2%) were considered true bacteremia. Trend analyses for the incidence of true bacteremia according to qSOFA and A-DROP scores did not show any statistically significant results (p=0.49 for qSOFA; p=0.14 for A-DROP). The proportion of true bacteremia cases did not differ significantly between survivors and non-survivors. Conclusions The incidence of true bacteremia among NHCAP patients was very low. A strategy for determining indications for obtaining blood cultures from NHCAP patients needs to be established.

Impact of initial empirical antimicrobial choice and cause of in-hospital death in patients with nursing and healthcare-associated pneumonia (NHCAP): A retrospective study.

To examine the differences in antimicrobial selection outcomes in nursing and healthcare-associated pneumonia (NHCAP) patients with and without risk factors for drug-resistant pathogen (RDRP) infection, and to identify the cause of in-hospital death after improvement of NHCAP. We conducted a retrospective analysis of the medical records of hospitalized adult patients with NHCAP. NHCAP patients were divided into the RDRP and non-RDRP groups. The RDRP group was further classified into the narrow and broad subgroups according to the type of empirical antimicrobial agent selected. The difference in mortality between these subgroups was then examined. The cause of all in-hospital deaths was also evaluated. e evaluated 220 patients with NHCAP. There was no difference in mortality between the narrow and broad subgroups (11.8% vs. 15.4%, p=0.655). Among the group with improved NHCAP, 11.3% (n=23/203) died in hospital before discharge. Although the causes of death in patients who improved after NHCAP were diverse, the most common was recurrence of pneumonia. Empirical antimicrobial therapy for NHCAP may not always require selection of broad-spectrum antimicrobial agents, as has been previously reported. Patients with NHCAP may die from other causes, even after NHCAP has improved.

Clinical features of nursing and healthcare-associated pneumonia due to COVID-19

IntroductionThe objective of this study was to clarify the clinical differences between nursing and healthcare-associated pneumonia (NHCAP) and community-acquired pneumonia (CAP) due to COVID-19. We also investigated the clinical characteristics to determine whether there is a difference between the variant and non-variant strain in patients with NHCAP due to COVID-19. In addition, we analyzed the clinical outcomes in NHCAP patients with mental disorders who were hospitalized in a medical institution for treatment of mental illness. MethodsThis study was conducted at five institutions and assessed a total of 836 patients with COVID-19 pneumonia (154 cases were classified as NHCAP and 335 had lineage B.1.1.7.). ResultsNo differences in patient background, clinical findings, disease severity, or outcomes were observed in patients with NHCAP between the non-B.1.1.7 group and B.1.1.7 group. The median age, frequency of comorbid illness, rates of intensive care unit stay, and mortality rate were significantly higher in patients with NHCAP than in those with CAP. Among the patients with NHCAP, the mortality rate was highest at 37.5% in patients with recent cancer treatment, followed by elderly or disabled patients receiving nursing care (24.3%), residents of care facilities (23.0%), patients receiving dialysis (13.6%), and patients in mental hospitals (9.4%). ConclusionsOur results demonstrated that there were many differences in the clinical characteristics between NHCAP patients and CAP patients due to COVID-19. It is necessary to consider the prevention and treatment content depending on the presence or absence of applicable criteria for NHCAP.

Inflammatory biomarkers are not useful for predicting prognosis in nursing and healthcare-associated pneumonia: A prospective, cohort study

IntroductionWhether inflammatory biomarkers including procalcitonin (PCT) and C-reactive protein (CRP) are useful for predicting prognosis in nursing and healthcare-associated pneumonia (NHCAP) is unknown. The aim of the present study was to investigate the utility of serial PCT and CRP measurements for predicting prognosis and treatment efficacy for hospitalized NHCAP patients. MethodsThis prospective, observational, cohort study enrolled consecutive NHCAP patients hospitalized at Kurashiki Central Hospital from October 2010 to September 2017. PCT and CRP were measured twice, once on admission and again within 48–72 h after admission. The primary outcome was 30-day all-cause mortality, and the secondary outcome was initial treatment failure. ResultsA total of 299 patients were included. The 30-day mortality rate was 8.4% (25/299), and the initial treatment failure rate was 15.4% (46/299). On multivariate analysis, performance status [odds ratio (OR) (95% confidence interval (CI)): 2.25 (1.34–3.77), P = 0.002], temperature [OR (95%CI): 0.53 (0.32–0.88), P = 0.02], heart rate [OR (95%CI): 1.03 (1.01–1.06), P = 0.007], albumin [OR (95%CI): 0.42 (0.18–0.95), P = 0.04], and blood urea nitrogen [OR (95%CI): 1.02 (1.00–1.05), P = 0.04] were significant prognostic factors, and CRP D3 [OR (95%CI): 1.07 (1.02–1.11), P = 0.003] and PSI [OR (95%CI): 1.01 (1.00–1.02), P = 0.01] were the predictors of initial treatment failure. Consecutive measurements of PCT and CRP were not significant predictors of 30-day mortality. ConclusionsInflammatory biomarkers including PCT and CRP were not useful for predicting prognosis and treatment efficacy in NHCAP patients. We should carefully evaluate the patients’ vital signs and comorbidities when managing NHCAP patients.

Efficacy and validity of guideline-concordant treatment according to the JRS guidelines for the managements of pneumonia in adults updated in 2017 for nursing and healthcare-associated pneumonia. A propensity-matching score analysis

IntroductionPatients with nursing and healthcare-associated pneumonia (NHCAP) commonly receive empiric antibiotic therapy according to the guideline's recommendation corresponding to the patient's deteriorated conditions. However, it is unclear whether guideline-concordant treatment (GCT) could be effective or not. Patients and methodsTo evaluate the efficacy and validity of GCT according to the current guideline for pneumonia, we conducted this retrospective study. NHCAP patients who were admitted to our institute between 2014 and 2017 were enrolled. Based on the initial antibiotic treatment, these patients were divided into two groups, the GCT group (n = 83) and the non-GCT group (n = 146). Propensity score matching (PSM) was used to balance the baseline characteristics and potential confounders between the two groups. After PSM, patients’ characteristics, microbial profiles, and clinical outcomes were evaluated. ResultsBoth groups were well-balanced after PSM, and 78 patients were selected from each group. There were no differences in patients’ characteristics or microbial profiles between the two groups. As for outcomes, there were no differences in 30-day, in-hospital mortality rate, duration of antibiotic treatment, or admission. The severity of pneumonia was more severe in patients with the GCT group than those with the non-GCT group. Anti-pseudomonal agents as initial treatment were more frequently seen in patients with the GCT group than those in the non-GCT group. ConclusionUnlike previous studies, GCT's recommendation for management of pneumonia by the JRS in 2017 would appear to be valid and does not increase the mortality rate.

Evaluation of pneumonia severity scoring systems in nursing and healthcare-associated pneumonia for predicting prognosis: A prospective, cohort study

The usefulness of existing pneumonia severity indices for predicting mortality in nursing and healthcare-associated pneumonia (NHCAP) is unclear. This study compared the usefulness of existing pneumonia severity indices for predicting mortality in NHCAP and community-acquired pneumonia (CAP). Consecutive hospitalized pneumonia patients including NHCAP and CAP patients were prospectively enrolled between October 2010 and November 2017. Admission pneumonia severity was assessed using CURB-65, Pneumonia Severity Index (PSI), A-DROP, Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) severe pneumonia criteria, and I-ROAD. The primary outcome was 30-day mortality. The discriminatory ability of each severity index was evaluated by receiver operating characteristic curve analysis. Overall, 828 patients had NHCAP, and 1330 patients had CAP. Thirty-day mortality was 12.8% and 5.6% in NHCAP and CAP patients, respectively. The area under the curve of PSI (0.717, 95% confidence interval 0.673–0.761) was the highest among all pneumonia severity indices, with significant differences compared with CURB-65 (0.651, 95% confidence interval 0.598–0.705, P = 0.02) and IDSA/ATS severe pneumonia criteria (0.659, 95% confidence interval 0.612–0.707, P = 0.03). The predictive abilities for 30-day mortality of the pneumonia severity indices, excluding PSI and I-ROAD, were significantly inferior for NHCAP than for CAP. PSI may be the most useful pneumonia severity score for predicting mortality in NHCAP. However, the predictive ability for mortality of each pneumonia severity score was worse for NHCAP than for CAP; therefore, the prognostic factors in NHCAP need to be identified for better management of NHCAP patients.

Changes in physical function after hospitalization in patients with nursing and healthcare-associated pneumonia

To clarify the functional changes after hospitalization due to pneumonia in elderly Japanese patients, we investigated the changes in physical functioning, nutritional routes, and diet that occurred after hospitalization in patients with nursing and healthcare-associated pneumonia (NHCAP). We analyzed 405 patients with NHCAP and compared findings with 448 patients with community-acquired pneumonia (CAP). Among the NHCAP patients, 140 (34%) patients showed a decline in activities of daily living function between baseline and discharge. After hospital discharge, 149 (37%) NHCAP patients did not return to the same residence location compared with where they were living prior to hospital admission. The frequency of this outcome was significantly higher in NHCAP patients than in CAP patients (p<0.0001). After 6 months' follow-up, of the patients who transferred to different hospitals, 41 (73%) patients with CAP had returned to their own home, but only 16 (20%) patients with NHCAP could return home (p<0.0001). Rates of alteration of nutritional route and type of diet from oral nutrition were significantly higher in NHCAP patients compared with CAP patients (22% vs 4%, p<0.0001). Our results demonstrated that approximately one-third of hospitalized patients with NHCAP showed a decline in physical function. In addition, approximately one-fifth of NHCAP patients had changed their route of nutrition and type of diet. Our results indicated that physicians should attach greater importance to preventative measures against NHCAP rather than relying on antibiotic therapy post-infection in the management of pneumonia in elderly patients in order to extend their healthy life expectancy.

Effects of Ampicillin/Sulbactam Dose and Dosing Frequency in Elderly Patients with Nursing- and Healthcare-Associated Pneumonia (Nhcap)

Japan has the most rapidly aging population in the world. This study aimed to examine the differences in the efficacy of ampicillin/sulbactam (ABPC/SBT) alone under different daily doses and daily dosing frequencies in elderly patients receiving healthcare at home and in elderly nursing home residents with pneumonia onset requiring hospitalization for treatment. By applying the Clinical Practice Guidelines for Nursing- and Healthcare-associated Pneumonia (NHCAP) of the Japanese Respiratory Society (JRS), we retrospectively analyzed clinical data, dose, dosing period, and the efficacy of antimicrobial agents, as well as outcomes of patients with NHCAP or community acquired pneumonia (CAP) who had been hospitalized at our department during the 3-year period of 2009 through 2011. The mean age of NHCAP patients (n=587) was 85 ± 9 years, significantly higher than the 77 ± 16 years of CAP patients (n=319). The serum albumin level in NHCAP patients was significantly lower than that in CAP patients. Among NHCAP patients, 82.5% received ABPC/SBT alone as the first-line therapy, with 50.7% receiving 1.5 g three times daily and 22.8% receiving 3 g twice daily. The mortality rate during hospitalization in the 1.5-g three-times-daily group was 12.4%, resulting in a significantly decrease as compared with the 3-g twice-daily group of 20.9% (p<0.01). In our study, which targeted the elderly in Japan, it was revealed that ABPC/SBT is an appropriate first choice of antibiotics in treating NHCAP and that administering 1.5 g three times daily is a suitable way of administration.

Clinical effect of biapenem on nursing and healthcare-associated pneumonia (NHCAP).

The clinical effect of Biapenem (BIPM) on Nursing and Healthcare-associated pneumonia (NHCAP) was evaluated. One hundred and three NHCAP patients (Group B: 52 patients, Group C: 51 patients) to whom BIPM was administered were included in this study. Clinical effect, bacteriological effect, and adverse events were examined. Results revealed efficacy in 45 of 52 patients (efficacy rate: 86.5%) of NHCAP Group B, and 43 of 51 patients (efficacy rate: 84.3%) of NHCAP Group C, 88 of 103 patients (efficacy rate: 85.4%) as a whole. As for bacteriological effect, 10 (76.9%) of 13 Pseudomonas aeruginosa strains, 9 (90.0%) of 10 Klebsiella pneumoniae strains, 7 (87.5%) of 8 methicillin-sensitive Staphlococcus aureus strains, and 7 (100%) of 7 Streptococcus pneumonia strains were eradicated. As a whole, 38 (80.9%) of 47 strains were eradicated. Adverse events included drug fever and drug eruption in one patient each, and abnormal laboratory findings, including mild hepatic dysfunction in 18 patients and mild renal dysfunction in 5 patients. Based on the above, it was concluded that BIPM shows excellent clinical effect on NHCAP with fewer adverse events.

Retrospective analysis of nursing and healthcare-associated pneumonia: Analysis of adverse prognostic factors and validity of the selection criteria

Nursing and healthcare-associated pneumonia (NHCAP) is a relatively new condition that was recently defined by the Japanese Respiratory Society. Previous reports and guidelines have not thoroughly investigated the adverse prognostic factors and validity of the selection criteria for NHCAP. The purpose of this research was to clarify the adverse prognostic factors of NHCAP and investigate the validity of the selection criteria with respect to patient deaths. We retrospectively analyzed 418 patients with pneumonia who were admitted to our hospital between January 2009 and December 2011. We analyzed 215 (51.4%) cases of community-acquired pneumonia (CAP) and 203 (48.6%) cases of NHCAP. NHCAP patients were generally older and had poorer performance status (PS), more complications, and higher levels of mortality than CAP patients. In both groups, the most common causative pathogen was Streptococcus pneumoniae. A multivariate analysis of NHCAP revealed that age ≥ 80 years, oxygen saturation (SpO2) ≤ 90%, and methicillin-resistant Staphylococcus aureus (MRSA) infection to be independent factors associated with mortality. Of the NHCAP selection criteria, a PS ≥ 3 and a hospitalization history within the past 90 days were adverse prognostic factors in the broad community-acquired pneumonia category (CAP+NHCAP), according to a multivariate analysis. Univariate analysis revealed that admission to an extended care facility or nursing home was associated with death. Our results demonstrated that age ≥ 80 years, SpO2 ≤ 90%, and MRSA infection were adverse prognostic factors for NHCAP patients. Furthermore, we confirmed the validity of the NHCAP selection criteria.

A prospective comparison of nursing- and healthcare-associated pneumonia (NHCAP) with community-acquired pneumonia (CAP)

Nursing- and healthcare-associated pneumonia (NHCAP) has been proposed by the Japanese Respiratory Society as a new category of pneumonia considering the characteristics of the Japanese medical care environment. It is necessary to ascertain the epidemiology and clinical outcomes of NHCAP. A prospective study was conducted of patients with pneumonia who were hospitalized at our hospital from August 2011 to July 2012. We compared 192 cases of NHCAP with 114 cases of community-acquired pneumonia (CAP). Compared with CAP, NHCAP had a higher disease severity, higher 30-day mortality rate (10.9vs. 3.5%, P=0.022), and longer length of hospital stay (median, 12 vs. 8days, P<0.001). Streptococcus pneumoniae was the most frequent causative pathogen in both NHCAP and CAP (33.9vs. 34.8%, P=0.896). The incidence of atypical pathogens in NHCAP was low (1.7%). Multidrug-resistant (MDR) pathogens were isolated more frequently in NHCAP than in CAP, but there was no significant difference (11.0 vs. 4.5%, P=0.135). Among 192 NHCAP patients, 122 (63.5%) were aspiration pneumonia. Aspiration pneumonia was associated with poor outcomes and was considered a major characteristic of NHCAP. Our study suggested that many patients with NHCAP do not need broad-spectrum antibiotic therapy targeting MDR pathogens. Excess mortality in NHCAP patients is the result of patient backgrounds or disease severity rather than the presence of MDR pathogens.

医療・介護関連肺炎ガイドラインに従った耐性菌カバーと治療アウトカムとの関連についての検討

The nursing and healthcare-associated pneumonia (NHCAP) guidelines recommend broad-spectrum antibiotics usage when the presence of multidrug resistant pathogens is anticipated. However, it has not been proved that guidelines-concordant treatment improves the outcome. To clarify the impact of guidelines-concordant treatment on the outcome of NHCAP patients. This was a single-center, medical record based retrospective study. The outcomes of NHCAP patients who were treated with guidelines-concordant antibiotics were compared with those of the patients who were not so treated. Then, along with other parameters such as pneumonia severity or patient backgrounds, we analyzed what parameters affected the outcome of NHCAP. Two hundred and twenty-six admissions were analyzed. Guidelines-concordant treatment did not show significant correlation with 30 days mortality, in-hospital mortality or treatment failure. A multivariate analysis showed a significant correlation between the treatment outcome and no parameters other than "Classified into severe-group of community-acquired pneumonia". Even in the analysis limited to the patients who were actually proved to possess drug-resistant pathogens, the antibiotic coverage of the pathogens did not show any correlation with the outcomes. NHCAP guidelines-concordant treatment might not improve the patient outcome.

Reevaluation of the Japanese guideline for healthcare-associated pneumonia in a medium-sized community hospital in Japan

The Japanese guidelines for nursing- and healthcare-associated pneumonia (NHCAP) categorize patients by risk of resistant bacteria and defined antimicrobials to be used, similar to the healthcare-associated pneumonia (HCAP) guidelines of the United States. The data were collected in large-scale hospitals, possibly a cause of inconsistency with everyday practice in medium-sized community hospitals. To test the feasibility of this guideline based on a retrospective study performed in a medium-sized community hospital in Japan, the medical records of pneumonia patients were retrospectively studied [718 patients: NHCAP, 477, 66.4%; community-acquired pneumonia (CAP), 241, 33.4%). Factors related to patients' background, clinical and laboratory findings, treatment, and outcome were compared between NHCAP and CAP. The A-DROP system, scored by age, dehydration, respiratory failure, disorientation, and low blood pressure, evaluated the severity of pneumonia. In contrast to CAP patients, NHCAP patients included more elderly patients requiring nursing care and revealed higher rates of poor nutrition, dementia, aspiration, severe cases, detection of drug-resistant bacteria, and mortality. For NHCAP, the success rate did not differ between those receiving and not receiving proper initial treatment (76.9 vs. 78.5%) nor did mortality rate within 30days differ (13.1 vs. 13.8%). Risk factors for mortality within 30days for NHCAP were diabetes [adjusted odds ratio (AOR) 2.394, p=0.009], albumin <2.5g/dl (AOR 2.766, p=0.002), A-DROP very severe (AOR 1.930, p=0.021), and imaging showing extensive pneumonia (AOR 2.541, p=0.002). The severity of pneumonia rather than risk of resistant bacteria should be considered, in addition to ethical concerns, in initial treatment strategy in NHCAP to avoid excessive use of broad-spectrum antimicrobials.

Clinical Characteristics of Nursing and Healthcare-Associated Pneumonia: A Japanese Variant of Healthcare-Associated Pneumonia

The aim of this study was to describe the epidemiology, clinical features, antimicrobial treatment, and outcomes of patients with nursing and healthcare-associated pneumonia (NHCAP); a new category of pneumonia proposed by the Japanese Respiratory Society. We conducted a retrospective analysis of a prospectively collected database of patients with NHCAP and community-acquired pneumonia (CAP) hospitalized at a single center between January 2008 and December 2010, and compared their clinical characteristics. The criteria for NHCAP were as follows: (1) residence in a nursing home or an extended-care ward, (2) a discharge from a hospital in the preceding 90 days, (3) an elderly or handicapped patient who needs long-term care, (4) a patient who regularly requires vascular access in an outpatient setting. A total of 442 NHCAP patients and 451 CAP patients were evaluated. The NHCAP patients were older and had a higher frequency of underlying diseases. Aspiration was thought to be associated with the NHCAP in 63% of patients. Streptococcus pneumoniae was the leading pathogen in both groups, whereas the frequency of multidrug-resistant pathogens was higher in the NHCAP patients. The most frequently used antimicrobials in NHCAP patients were penicillins with beta-lactamase inhibitors. The in-hospital mortality and recurrence rates were significantly higher in NHCAP patients than in CAP patients (13.1% vs. 5.1%, p<0.001 and 18.8% vs. 5.5%, p<0.001). The clinical picture of NHCAP is consistent with that of HCAP described in the past. It is thought to be of benefit to modify the healthcare-associated pneumonia (HCAP) criteria considering the healthcare and social health insurance system in Japan.

Clinical Features and the Role of Atypical Pathogens in Nursing and Healthcare-associated Pneumonia (NHCAP): Differences between a Teaching University Hospital and a Community Hospital

The Japan Respiratory Society documented a new category of guidelines for nursing and healthcare-associated pneumonia (NHCAP), which is distinct from community acquired pneumonia (CAP). The objective of this study was to determine the epidemiological differences between NHCAP patients in a teaching university hospital and a community hospital. In addition, to clarify the strategy for treatment of NHCAP, we investigated the role of atypical pathogens. We analyzed 250 NHCAP and 421 CAP cases in a university hospital and 349 NHCAP and 374 CAP cases in a community hospital. Patient age and the incidences of poor general condition were significantly higher in the community hospital compared with those in the university hospital. The distribution and frequency of pathogens, especially multidrug-resistant (MDR) pathogens, were significantly different between the two hospitals. Central nervous system disorders, dementia and poor performance status, which was possibility related to aspiration pneumonia, were significantly more frequent in patients with NHCAP compared with those with CAP in both hospitals. Atypical pathogens were detected in a few cases in patients with NHCAP. There were many differences in the clinical characteristics between NHCAP patients in a university hospital and a community hospital even for hospitals located in the same area. Aspiration pneumonia was thought to be the main characteristic of NHCAP in both hospitals. Thus, all NHCAP patients did not need the same empiric therapy with a multidrug regimen directed against MDR pathogens. In addition, physicians rarely need to consider atypical pathogens in NHCAP treatment.

Guest Editor’s Introduction

Background and aim: Nursing- and healthcare-associated pneumonia (NHCAP) is a new concept, proposed by the Japanese Respiratory Society in 2011 (Kohno S, et al. Respir Investig 2013; 51:103-126). It is a modification of the healthcare-associated pneumonia described for the US to more accurately reflect the situation in Japan. The optimal treatments for NHCAP are still unclear. Although NHCAP patients often have drug-resistant pathogens, it has been reported that the outcomes do not depend on the antibiotics administered, but on the status of the patients. To evaluate the contribution of the broad-spectrum antibiotics for high-risk NHCAP, we examined the admitted NHCAP patients. Methods: We retrospectively examined 172 patients who met the NHCAP criteria and the definition of high-risk pneumonia. The criteria for NHCAP were as described in the NHCAP guidelines. The definition of high-risk was a severe or very severe classification, or a Performance status of 3 or 4. We divided the high-risk patients into two groups. In the Narrow group, patients were treated with narrow-spectrum antibiotics, while the patients treated with broad-spectrum antibiotics were included in the Broad group. The patient survival was analyzed using Kaplan-Meier curves and the log-rank test. Results: There were 127 in the Narrow group and 45 in the Broad group. The 30-day mortality rates were 12.6% and 24.4%, respectively. Although the difference was not significant, the survival rate of the Narrow group tended to be higher than that of the Broad group (p = 0.08). Conclusions: We herein demonstrated that broad-spectrum antibiotics did not improve the prognoses of high-risk NHCAP patients.